Case Conference-DepressionPREPARED BYWOO WING JUNELICIA CHIENG
Patient’s Particulars
Mr X29 year-old malay maleWorks as auditor in HSBC bankMarried for 3 years with no children
Chief Complaint
The patient was brought in to the emergency department by the father and presented with suicidal attempt by paracetamol overdosing of 10 tablets at one go on 18/11/2015.
What would you ask next?
History of Presenting Illness The wife requested for a divorce after his mother-in-law
passed away on the 1st October 2015 ( 2 weeks ago) The wife’s family blamed him for the death Previously, the mother-in-law had undergone renal transplant
in HKL in April 2015, but the patient was unable to pick her up upon discharge because his car was sent for service.
wife’s family were not happy with him Was informed that his mother-in-law was in critical condition
the day before her death, immediately booked tickets with his wife back to Miri. Able to see his mother-in-law before her death at 1.30pm, on 1/10/2015.
HOPI (continued) At the funeral, the father-in-law suddenly shouted in front of
the relatives and accusing him for causing his mother-in-law death
The wife changed the return tickets to the next Saturday(10th October) without notifying him, she insisted she will bear the extra charges on her own.
At the same time, the patient was tensed up with the urgent job in KL because his boss claimed that he would be reported to the Human resource department.
He ended up getting a warning letter from the HR department after he was back to KL on the Saturday.
What are the symptoms you would like to elicit from the
patient?
HOPI (continued) For the past 1 month,
felt depressed and disappointed vaped up to one bottle per day which he usually finished in 2
weeks had loss of interest in the things he used to do such as swimming,
bowling couldn’t concentrate and had poor attention at work leading to
poor performance of work, his boss started to pick on him frequently absent from work difficulty initiating sleep as he was preoccupied by his wife
Sleeps at 11pm, and frequently wakes up in the middle of night at 1am, 3am and 4am,felt weak and experienced headache in the morning the other day
loss of appetite waist circumference reduced from 46 inch to 38 inch, and
Tshirt size from XXXL to XL once suicidal ideation by jumping into the swimming pool no auditory hallucination no manic or hypomanic symptoms
Past psychiatry history
He was seen in the psychiatry clinic in 2011 for low mood after problems with his girlfriend who is now his wife.
He wasn’t given any medication that time.
Past medical history
patient had asthma, and last attack was at the age of 17
mid hypertensive and not on any anti-hypertensive medication
had done extracorporeal shock wave lithotripsy (ESWL) for removal of kidney stone in 2014
urinary tract infection within 2015
Family History Both the parents are in 70s Eldest brother is 47,married with 4
children, works as engineer Second brother is 41 with intellectual
disability with psychosis Third brother is 36, works as engineer
and married with 4 children Sister is 31, works as doctor in Miri,
married with 2 children Relationship with family members is
good. Otherwise, no other psychiatry
illness,suicide in the family
Personal History Perinatal history was unable to be elicited childhood obesity and asthma Average student, science stream active in sport such as taekwando, bowling and
swimming further his study in Degree of Accounting at UNITEN,
and subsequently took ACCA in gold coast, Australia many close friends from the school No major disciplinary problems
worked in hotel SPA for 2 months in Bahau after back from Australia, his mum asked him to back to KL.
So, started working in AIG for 3 months HSBC bank since 2008 until now
Love marriage, married for 3 years with no children Wife is studying quantity surveying Frequently argue over small matters wife had asked for divorce due to marital discord over
the past 1 month Financial constraint, earn 3k a month with car loan,
house loan, and credit card debts No criminal record noted
took alcohol (Heineken) on weekly basis when he was in UNITEN, average 3 big bottles each time
Stopped after back to Malaysia
denied cigarette smoking However, he vaped every day, and used to finish one
bottle in 2 weeks, but has been finishing a bottle each day
No substance or illicit drug use
Premorbid Personality
hot-tempered person sometimes likes to be alone likes to go on vacation vapes or heads to gym when he is stressful
Mental State Examination General appearance
well-groomed malay male dressed in hospital attire Unshaven, messy hair Conscious and forthcoming maintained good rapport and eye contact but at times, he
distracted by surrounding people no abnormal movement noted
Speech and thought Speech is coherent and relevant with normal amount, tone
and rate Has suicidal thought (jumping into pool or fire)
Mood and Affect Mood is euthymic and was congruent to the affect
Perception no hallucination (but he reports hearing voices
asking to kill himself when he felt depressed in the ward)
No illusion, flashbacks, depersonalization, and derealization
Cognitive function Orientation
disorientated to time, place and person Memory
remote and recent memory were intact Able to recall 3 out of 5 words in the 5 minute work
test Information and Vocabulary
appropriate to his age, education level and sociocultural background
Abstraction able to tell the similarities between apple and orange
in abstract manner Attention and concentration
couldn’t perform serial 7 test but he managed to count digit span and spell “world” backward
Judgement impaired as he would jump into fire when he saw a
building caught on a fire Insight
Good insight
Provisional diagnosis Severe Major depressive disorder with
psychosis
Differential Diagnosis
Prodrome of schizophrenia Schizoaffective disorder Bipolar disorder in depressive phase
Investigation
Full blood count Liver function test Renal function test Thyroid function test ECG
Psychiatric Formulation
AetiologyBIO PSYCHO SOCIAL
Predisposing factors
• Dependent personality
• Pampered child• Hot-tempered
• Financial constraint• Frequent argument with
wife• Disliked by the wife’s
family
Precipitating factors
• Divorcement • Difficulties in work
Perpetuating/maintaining factors
• Unresolved marriage problem
ManagementBIO PSYCHO SOCIAL
Acute
• Detoxification• Anti psychotics for
auditory hallucination • Anti depressants
(Escitalopram)• Admitting patient to
ward to monitor
• Allow patient to vent or speak out his problems
• Family support
Long Term
• Anti depressants• Electroconvulsive
therapy (if treatment resistant, high suicidal risk)
• Cognitive behavioural therapy
• Psychodynamic therapy• Supportive
psychotherapy
• Marriage counsellor• Social support from
family members
THANK YOU!
ANY QUESTIONS?